If suspected then d/w med control for considerate of immediate reduction and splinting vs. rapid transport to ED

If no suspicion the patient can be immobilized in current position

Don’t forget C-spine precautions as these injuries are often distracting

Overview

Etiology:

Typically traumatic in origin

Over 2/3 Hip dislocations occur in patients who present after MVCs without seat belts with the knee hitting the dashboard and the body moving forward over a fixed femur.

Often associated with posterior wall/lip fractures of the acetabulum

Definitions:

Simple vs. Complex

Simple Dislocation – does not involve fracture

Complex Dislocation – involves fracture

Pathophysiology:

Posterior & Inferior dislocations are most common – about 90% of dislocations

Fracture of >40% of the acetabular rim is considered an UNSTABLE FRACTURE (requires ORIF)

If there is a posterior acetabular fracture you must get a CT to eval for unstable fractures

Sciatic nerve injury

Seen in about 14% of traumatic hip dislocations

Check sensory along the posterior leg, ability to dorsiflex the ankle and ankle reflexes

95% of traumatic hip dislocations will have another associated injury

Be sure to complete a full trauma survey on these patients per ATLS guidelines

Imaging

Initial image should be a bedside AP pelvic radiograph

Look for Shenton’s Line

Lateral film can seal the diagnosis if unsure based on initial bedside AP

CT if neeeded

Treatment for Native Hips (non-prosthetic)

Consultation

Ortho Consultation are required for the following:

Complex hip dislocations

Irreducible dislocations

Non-concentric reductions

Neurovascular deficits despite reduction

Reductions

Who:
– Simple dislocations can & should be reduced by the ED physician!

When:
– Reduction should be performed within 6 hours of injury to decrease risk of avascular necrosis
– No more than 3 attempts at reduction should be made by the ED provider

Transfers:
– If patient requires transfer to a different hospital, an attempt at reduction should be made by the ED provider.
– Patients transferred without reduction had a 4-fold risk of severe sciatic nerve compared to those transferred after reduction (16% vs 4%).

Analgesia:
– Be sure pain is controlled prior to attempting reduction

Ultrasound guided fascia iliaca compartmental block work great

Reduces need for systemic analgesics

Improves patient comfort

Increases likelihood of successful reduction

Reduce need for procedural sedation

Be sure to have completed a full neurological exam prior to blocking your patientLINK TO VIDEO

In many cases, procedural sedation and systemic analgesia may also be needed (in addition to nerve block) in order to adequate pain control and muscle relaxation.

After successful reduction the hip should be immobilized in extension and external rotation with slight abduction
– Use an abduction pillow to help hold this position
– Knee immobilizer can be used if no abduction pillow is available

Don’t forget to obtain a post reduction film to confirm alignment

Other Recommendations
– Early passive range of motion and rehab is usually recommended
– Patients should remain non-weight bearing until seen by an Orthopedist

Notes on Prosthetic Hip Dislocations

Quite common

Incidence of ~2% of patients who undergo THA

60% occur within first 3 mo, 77% occur within the first year

Often the result of minimal force like bending over to pick something up off the floor

Use the same techniques as a native hip reduction

Do not need abduction bracing after the reduction

If the patient can walk after the reduction, they can be safely discharged (after discussion with their orthopedist)

Less urgency, no risk of avascular necrosis as the femoral head has already been replaced

Remember, these injuries are painful and although less urgent, the reduction should occur as soon as possible

Prophylactic antibiotics for surgical patients in tube thoracostomy is usually limited to 24hrs duration and is 1st generation cephalosporin. It is meant to cover s. aureus the most common organism found in post traumatic empyema

increasing antibiotic use is leading to increase incidence of drug resistance

Literature is mixed on whether antibiotics should be given for chest tubes placed for trauma.

In 1998 EAST guidelines gave a level 3* recommendation to give antibiotics prophylacticly to reduce incidence of pneumonia based off of Class I and Class II** data. AND there was insufficient data to give prophylactic antibiotics for post traumatic empyema

This recommendation remains controversial because

In order for antibiotics to be prophylactic they have to be given prior to a procedure and must reach a steady state concentration in the tissue before an incision is made.

In the case of antibiotics given after a trauma has already occurred, the pleura has already been violated regardless of whether it is penetrating or blunt trauma. Therefore antibiotics do not reach needed concentration before contamination has concerned so these antibiotics are considered presumptive antibiotics.

Non standard definitions of pneumonia and empyema were used, as well as various antibiotics were used in the different studies

In 2012 EAST guidelines reviewed the use of presumptive antibiotics for chest tubes (Tube thoracostomy):

They decided that they cannot make a recommendation for or against the routine use of presumptive antibiotics for chest tubes placed for traumatic hemopneumothorax.

Nor are they able to recommend an optimal duration of antibiotic prophylaxis when antibiotics are administered for traumatic hemopneumothorax because there are insufficient published data to support the routine use of antibiotics.

They concluded:

No single published study has been powered to adequately address the practice of administering presumptive antibiotics in TT for traumatic hemopneumothorax to decrease the incidence of empyema or pneumonia. Until a large and likely multicenter, randomized, controlled trial can be performed, the routine practice of presumptive antibiotics in TT for chest trauma will remain controversial.

Lisfranc injures are a spectrum which result in a sprain or complete disruption of the tarsometatarsal joints of the midfoot. They most commonly occur at the base of the 2nd metatarsal with oftentimes subtle or even absent findings on standards x-ray views, especially when they result from low velocity injury.

What is mechanism of Injury?

Usually a result of plantar flexion with external rotation of the ankle (ie. fall from a horse with the foot caught in the foot stirrup, MVC, foot planted in a hole or step off a curb)

Physical Exam on Suspected Lisfranc Fracture

Unable to bear weight

Hematoma/ecchymosis on medial plantar aspect of foot

Dorsal midfoot swelling

For suspected Lisfranc injuries you’ll need three views (AP, lateral and oblique). On normal foot x-rays you should notice alignment of the 2nd metatarsal on AP view and the medial edge of the base of the 2nd metatarsal should line up with the medial edge of the medial cuneiform. On the oblique view the 3rd and 4th metatarsal should have the medial edge of the 3rd and 4th metatarsal lining up with the medial edges of the middle and lateral cuneiform.

Common X-ray findings for Lisfranc Fracture.

Widening of > 2mm between the base of the 1st and 2nd or 3rd and 4th metatarsal bases needs surgical intervention

“ Fleck Sign” is pathognomonic for a Lisfranc Injury. This is a small bony fragment avulsed from the 2nd metatarsal base or medial cuneiform

What if the X-ray is normal but a Lisfranc injury is still clinically suspected?

In patients with clinically suspected Lisfranc injuries and normal or indeterminate radiographic findings, CT or MRI imaging is recommended.

Given the superior depiction of soft tissue supporting structures and the ability of soft tissue supporting structures and the ability to detect soft tissue injuries in patients with unstable injuries on MR images, the American College of Radiology Appropriateness Criteria guidelines favors the use of MR imagining

Orthopedics surgeons may request high resolution 3D CT images for preoperative planning and for depicting and further characterizing fractures.

ED management for patients with Lisfranc Injury

For nondisplaced or suspected injury without radiographic findings, you may place the patient in a posterior back slab. Patient should be non-weight bearing and arrange for orthopedic outpatient follow up two weeks later. For significantly displaced injury or dislocation (> 2mm widening at the Lisfranc Joint) , Immediate orthopedic referral is needed for urgent outpatient surgical intervention

A weekend warrior trying to finish up painting that last side of the house takes a tumble off his ladder and lands on his left hand. He has a palpable deformity on the volar aspect of the distal radius and painful active and passive ROM but is otherwise neurovascularly intact with no median nerve neuropathy. The following x-ray is obtained:

You realize something is not where it’s supposed to be! The patient has a lunate dislocation to the point where it has migrated proximally to the forearm. After attempts at closed reduction by the Orthopedist, a CT is obtained which shows associated triquetral fracture and improved position of the lunate. The patient is admitted and scheduled for open reduction and repair of intercarpal ligaments in the OR.

Lunate and perilunate dislocations come in a variety of shapes and sizes but the orthopedists organize them into 4 different stages of instability that we’ll go over here.

Stage 1 instability: Scapholunate dissociation

Typically these patients FOOSH’d onto their wrist sustaining the injury with minimal swelling and pain on physical exam. On xray we are looking for widening of the scapholunate space of > 2-4mm which is our indication that there has been disruption of the ligament. You’ll hear the term, the “Terry Thomas” sign to describe the gaping of the metacarpals similar to his teeth. Depending on the orthopedist these can be managed conservatively with a sugar tong splint or operatively.

Stage 2 instability: Perilunate dislocation

These injuries will typically be a higher mechanism of injury with more significant physical exam findings than the stage 1’s we just discussed. On x-ray you’ll notice that the lunate remains aligned with the distal radius while the remaining carpal bones are displaced, usually dorsally. Most of the time these are going to need a CT to look for any radiooccult fractures of the scaphoid and radial styloid. These will need operative management to prevent any of the nasty sequelae of median nerve palsy, compartment syndrome, long term wrist dysfunction, etc.

Stage 3 instability: Midcarpal dislocation

These are going to have a similar mechanism of injury but result in disruption of the triquetrolunate ligament or a triquetral fracture. The radiographs will show neither the capitate or lunate aligned with the distal radius. You’re going to need ortho for this one.

Stage 4 instability: Lunate dislocation

These aren’t known to be the most common, but they are more severe. The differentiating factor between this and a perilunate dislocation is that the lunate and distal radius articulation is preserved in perilunate dislocation, but not so in lunate dislocations. On the AP film you’ll see the “piece of pie” sign (below, left) and on the lateral you’ll see the “spilled teacup” (below, right). This is yet another one that you’re going to get ortho involved with pretty early on for an urgent reduction and operative management.

We talk a lot about those pesky radiooccult scaphoid fractures and have seen enough distal radius fractures to make us physically ill, but there’s a lot more that can go wrong in the wrist. These are, for the most part, relatively apparent injuries that have devastating consequences if missed. So get ortho involved early in these cases so the patient can receive the treatment they need.

Being in even the most benign car accident imaginable, can be stressful for patients. Inherently, if they have any chest pain they’re going to be convinced that they’ve sheared their aorta right off its hinges. While that may be of concern to them, we are pretty certain that their aorta is still intact if they still are alive, but did they sustain a cardiac contusion? How do we figure out if they had one? And what the heck do we do with them if they did in fact have a cardiac contusion?

But the practical answer may be no. There are other studies that are less optimistic regarding the sensitivity and specificity and discourage the use of troponin as a gold standard for diagnosing cardiac contusion from blunt trauma. Another study showed that positive troponins were not a strong predictor of abnormalities on echocardiogram. So getting a troponin may not even matter. However other studies suggested that a positive troponin may be indicative of cardiac contusion or underlying cardiac issue, which brings us to our next question.

Probably not. Three older studies looked at outcomes of patients with cardiac contusions and they really have no long term sequelae and do well.

What’s the bottom line?

Being in a trauma center I would follow the trauma guidelines of getting both an EKG and troponin in the setting of blunt chest trauma. If this is negative with a negative EKG and the patient appears well clinically then likely discharge. However if they have an isolated positive troponin then I would consider admission for 24 hour monitoring for arrythmias with a consideration for inpatient echocardiogram with a reassuring knowledge that they will almost absolutely do well long term.

The weather is finally starting to warm up and the fish are biting. Unfortunately, amateur and pro fishermen alike will also either catch themselves or their friend while out on the waterways this summer. While a small fishhook lodged in a finger may seem trivial compared to some of the more traumatic injuries we see, the process of removing a fishhook can still be challenging and time consuming. In this month’s issue of ACEP Nowwe published four different ways of removing these pesty hooks. Check it out here.

There are two competing theories as what causes FES. Some believe more in the mechanical-obstruction theory where the fat globules act similarly as other embolic events, showering throughout the end organs and wreaking havoc by those means. The new challenger to this theory is the biochemical theory where proponents support the notion that the fat is broken down into free fatty acids and the damage is caused by the endothelial damage and subsequent increased vascular permeability. No matter which theory you support, the clinical diagnosis is going to be equally as challenging. There are a few criteria/scores that have been developed in the past that are non-specific diagnostic tools to identify patients with FES, but they have not been compared head-to-head in their accuracy. In the Emergency Department we are limited with the tests that we can routinely order. Unfortunately, CXRs are going to be essentially useless in diagnosing FES, but MRI may hold more promise. The starfield pattern seen on MRI is not specific to FES, but has been seen routinely in patients who have disease processes associated with FES along with neurologic symptoms. Otherwise, in the ED this is going to essentially be a clinical diagnosis with a good history and a little bit of luck. There is some evidence that earlier fixation and specific orthopedic surgery techniques may decrease the rate of FES, but from an EM point-of-view it is essentially supportive care. Research seems to be lacking into the non-trauma causes of FES, so maybe there is somewhere for us to intervene in those patients…

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Disclaimer: Information contained on this website is the opinion of the authors and does not represent the opinion of St. Joseph's Regional Medical Center or St. Joseph's Regional Medical Center Emergency Medicine Residency Program.